The present study examines how muscle dysmorphia (MD), a clinically
significant preoccupation that one's body is inadequately muscular,
relates to trait anxiety and obsessive-compulsive symptoms. 97
college-age men completed the MD Inventory, the Drive for Muscularity
Scale, the Male Body Attitudes Scale, the Social Physique Anxiety Scale,
the trait scale of the Speilberger State-Trait Anxiety Inventory, and an
abbreviated version of the Yale Brown Obsessive-Compulsive Scale.
Bivariate correlation analyses revealed that trait anxiety and
obsessive-compulsive symptoms demonstrated strong relationships with
both social physique anxiety and overall MD symptomology. Path analysis
indicated that anxiety-related variables accounted for 77 percent of the
variance in MD symptoms. The findings lend support to the assertion that
MD should be placed within the obsessive-compulsive spectrum of
disorders.

Although not officially listed in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (American
Psychiatric Association, 2000) (DSM-IV-TR), muscle dysmorphia (MD) is
recognized by many researchers as a legitimate psychological disorder.
Olivardia (2001) provides thorough diagnostic criteria for MD. First,
one must be preoccupied with the idea that his or her body is not
sufficiently lean or muscular. Second, the preoccupation must cause
clinically significant distress or impairment in social, occupational or
other important areas of functioning as demonstrated by (a) giving up
participating in important activities in these areas because of a
compulsive need to maintain diet and workout schedules, (b) avoiding
situations in which one's body is exposed to others, (c) exhibiting
clinically significant distress in these areas of functioning, (d)
continuing exercising, dieting, and using performance enhancing
substances despite negative physical or psychological consequences, and
(e) being preoccupied with being too small or inadequately muscular
rather than on being overweight.

Grieve (2007) discusses factors that influence the development of
MD. These include socio-environmental (media presentation of ideal
images and sports participation), emotional (negative affect and body
image dissatisfaction), psychological (idealized body image and low
self-esteem), and cognitive (perfectionism) influences (Grieve). Of most
interest to the present study are the emotional influences, especially
negative affect.

Maida and Armstrong (2005) noted positive correlations between
symptoms of MD and variables such as anxiety and obsessive-compulsive
symptoms. They examined a model in which obsessive-compulsive symptoms
were related to symptoms of eating disorders, body dysmorphic disorder,
and MD. Obsessive-compulsive symptoms were also directly related to
symptoms of MD. These findings indicate strong positive relationships
between obsessive-compulsive symptoms, anxiety, symptoms of body
dysmorphic disorder, and symptoms of MD, with the strongest relationship
being between obsessive-compulsive symptoms and symptoms of MD. However,
since Maida and Armstrong measured anxiety using the Brief Symptom
Inventory (BSI; Derogatis, 1984), which is a screening instrument for
psychiatric disorders, replication of these findings with a more
comprehensive evaluation of anxiety is in order. Moreover, Maida and
Armstrong did not directly evaluate symptoms of MD. They used a
combination of measures to suggest symptoms of MD. Thus, replication
with a measure designed to evaluate symptoms of MD is warranted.

Another variable of interest in terms of negative affect is social
physique anxiety, a body-related anxiety that stems from the fear of
others evaluating one's appearance (Hart, Leary, & Rejeski,
1989). Conceptually, symptoms of MD include concern over body shape and
hiding of the body (Olivardia, 2001). Further, prior research has
demonstrated a link between MD and social physique anxiety. Grieve,
Jackson, Recce, Marklin, and Delaney (in press) found that men who
reported higher levels of social physique anxiety also reported higher
levels of MD symptoms.

Two other variables--drive for muscularity and body focus--are
notable in the development of MD (Grieve, 2007). A drive for muscularity
underlies the behavioral symptoms of MD in that people with the disorder
want to be larger and more muscular than what they actually are
(Olivardia, 2001). There is a large body of research that ties a drive
for muscularity to MD (Thompson & Cafri, 2007). A second factor
important in the development of MD is body focus. Individuals high in MD
exhibit a number of body checking behaviors such as looking at their
bodies in mirrors (Olivardia, 2001).

The present study was designed to expand upon the work of Maida and
Armstrong, and evaluate the relationship that anxiety symptoms have with
MD. The model proposed for the study includes obsessive-compulsive
symptoms, trait anxiety, social physique anxiety, drive for muscularity
and media influences as factors that are related to MD. The general
model under study was taken from Grieve (2007), and was modified to
include the anxiety symptoms of interest to the present research.

Levels of anxiety are presumed to be motivational factors that will
influence both drive for muscularity and body locus. If individuals are
anxious about their appearance or display obsessive ideas about
appearance, it is likely that they will experience a higher level of
body focus. Because the social ideal for the male body is a
hypermesomorphic one (Grieve, Newton, Kelly, Miller, & Kerr, 2005;
Parks & Read, 1997; Ridgeway & Tylka, 2005), an acceptable way
to decrease body-related anxiety is to develop a drive for muscularity.

The study was designed to address two limitations noted in the
research by Maida and Armstrong: use of a screening instrument for
anxiety and not directly measuring the symptoms of MD. For the present
study, the trait section of the Speilberger State-Trait Anxiety
Inventory (Speilberger, Gorsuch, & Lushene, 1983) was used to
evaluate anxiety, and the Muscle Dysmorphia Inventory (Short, 2005) was
used to evaluate symptoms of MD.

The specific hypotheses under study are:

1. Higher levels of anxiety, measured as obsessive-compulsive
symptoms, levels of trait anxiety, and level of social physique anxiety,
will be associated with higher levels of MD symptoms.

2. Higher levels of anxiety will be associated with a higher body
locus and a higher drive for muscularity.

3. Higher levels of body focus and drive for muscularity will be
associated with higher levels of MD symptoms.

Methods

Participants

Participants in the study were 97 male volunteers recruited from a
mid-sized university in the mid-South. The mean age of the participants
was 21.75 years (SD = 4.52); the average height was 70.86 inches (SD =
2.71); and the mean weight was 184.11 pounds (SD = 44.12). Participants
had a mean body mass index of 26.29 (SD = 5.38). In all, 74 (85.1%)
participants were Caucasian, 5 (5.7%) were African American, 4 (4.6%)
were Asian, 1 (1.1%) was Hispanic, 1 (1.1%) was Pacific Islander, and 2
(2.3%) were bi-racial.

Thirty-two participants (36.8%) acknowledged using some form of
supplement while working out. Creatine, protein shakes, and vitamins
were the supplements mentioned most often. Forty-four (50.6%) reported
having an active gym membership; 64 (73.6%) said they participated in
cardiovascular exercise; 6 (6.9%) said they used topical analgesics
before working out and 12 (13.8%) reported using them afterwards; and 12
(13.8%) participants said they used pain medication before a workout
while 21 (24.1%) reported using them afterwards.

Measures

Demographics. Participants completed a 22-item demographics survey
assessing age, weight, height, and ethnicity. They were also asked about
active gym membership, frequency of working out, and use of supplements
to gain body mass.

Anxiety. The Speilberger State-Trait Anxiety Inventory (STAI;
Speilbergcr, Gorsuch, & Lushene, 1983) was used to assess for state
and trait-based levels of anxiety. The STAI is a 40-item self report
measure that assesses both how a person feels at the moment (state
anxiety) and how he or she generally feels (trait anxiety). The STAI
includes such statements as "I feel calm" and "I make
decisions easily." These items are rated on a four-point
Likert-type scale from 1 (not at all) to 4 (very much so). Because the
focus of this study is on the overall personality and long-term
characteristics of the participants, only the scores on trait anxiety
were used in the analysis. Higher scores indicate higher levels of trait
anxiety. Sansoni, Vellone, and Piras (2004) report a Cronbach's
Alpha of .95 for the trait version of the STAI. In the present study,
the Cronbach's alpha for the STAI was .95.

The Social Physique Anxiety Scale (SPAS; Hart, Leary, &
Rejeski, 1989) was administered to evaluate body anxiety. The SPAS
consists of 12 items that participants rate on a five-point Likert-type
scale from 1 (not at all) to 5 (extremely). Higher scores on the SPAS
indicate higher levels of social physique anxiety. Hart et al. (1989)
found that the SPAS demonstrates good internal consistency (r = .90) and
test-retest reliability (r = .82). In the present study, Cronbach's
alpha was .92.

An abbreviated version of the Yale Brown Obsessive-Compulsive Scale
(YBOCS; Goodman, Price, Rasmussen, & Mazure, 1989) was administered
to assess symptoms of obsessive-compulsive disorder. This version of the
YBOCS consists of 10 self-report items on which participants rank, on a
scale of 0 to 4, how much control they perceive themselves as having
over their obsessions or compulsions. Higher scores indicate higher
levels of obsessive-compulsive features. Frost, Steketee, Krause, &
Trepanier (1995) reported Cronbach's alphas for the total score as
.88. The Cronbach's alpha for the total score present study was
.92.

Muscle Dysmorphia. To assess for symptoms of MD, the Muscle
Dysmorphia Inventory (MDI; Short, 2005) was used. The MDI is a 25-item
questionnaire that assesses eight components of MD: Inadequacy,
Preoccupation, Muscularity Drive, Increased Muscularity, Compulsivity,
Body Anxiety, Social Sacrifice, and Persistence. Included in the MDI are
such items as "I feel badly when I do not get to work out."
Participants rank these items on a six-point Likert-type scale, from 1
(strongly disagree) to 6 (strongly agree). Higher scores indicate a
greater endorsement of MD symptomatology. In previous research, the MDI
has an overall Cronbach's alpha of .87 (Short, 2005). For the
present study, the Cronbach's alpha was .82.

Drive for Muscularity. To assess a participant's drive for
muscularity, the Drive for Muscularity Scale (DMS; McCreary & Sasse,
2004) was administered. The DMS is a 15-item questionnaire with
statements such as "I wish I were more muscular" and
"Other people think I work out with weights too much."
Participants rank these items on a six-point Likert-type scale, from 1
(always) to 6 (never). The DMS is reverse scored so that high scores
indicate higher levels of drive for muscularity (McCreary, 2007).
McCreary and Sasse (2004) found that the DMS had a Cronbach's alpha
of .87 among male participants. For the present study, the
Cronbach's alpha was .92.

Participants completed the demographics survey followed by the MDI,
DMS, MBAS, SPAS, YBOCS, and STAI. The entire process took about 20
minutes for each participant.

Results

Before addressing the conducted analyses, it is important to note
that there were ten participants who had missing data. This data was
replaced using mean substitution, and the participants were included in
the analyses.

Path analysis via a series of regressions (Pedhazur, 1997) was used
to examine relationships in the specified recursive model. As
illustrated in Figure 1, considered predictors of MD comprise three
exogenous variables, including Social Physique Anxiety, Obsessive
Compulsive Features, and Trait Anxiety, and two endogenous variables,
including Drive for Muscularity and Body Attitude. The path analysis is
the culmination of 12 regressions. Specifically, two regressions were
conducted assessing the contribution from each exogenous variable to
each endogenous variable. Then one regression was conducted from each
exogenous variable to MD, and one regression was conducted from each
endogenous variable to MD while accounting for the contributions from
the upstream exogenous variables. Path coefficients specified in Figure
2 are therefore the standardized beta weights from each regression. The
model also accounts for correlations between Social Physique Anxiety and
Trait Anxiety, Social Physique Anxiety and Obsessive Compulsive
Features, and Trait Anxiety and Obsessive Compulsive Features.

[FIGURE 1 OMITTED]

Figure 2 illustrates the path coefficients from the exogenous and
endogenous variables included in the model and also the correlations
among the exogenous variables. Most of the specified pathways had
statistically significant relationships. There were only two pathways
that did not achieve statistical significance. These were from trait
anxiety to drive for muscularity and from obsessive-compulsive features
to drive for muscularity. Overall, the total model [R.sup.2] denotes
that the predictors accounted for 73 percent of the variance in the
symptoms of MD. Given this large [R.sup.2], it is apparent that the
model possess acceptable goodness of fit.

[FIGURE 2 OMITTED]

Discussion

The results of the study support all of the hypotheses under study.
There were several strong relationships between trait anxiety, social
physique anxiety, obsessive-compulsive features, and MD symptoms. Trait
anxiety was found to be highly predictive of social physique anxiety. A
similar pattern of association was reported in women with disturbed
eating patterns (Bas, Asci, Karabudak, & Kiziltan, 2004). Trait
anxiety was also significantly negatively associated with body attitude;
that is, a higher level of trait anxiety was a reliable predictor of low
body attitude. This finding is consistent with past research completed
with women who have eating disorders.

Kashima, Tatsuhisa, Okamoto, Nogoshi, Wada, Tadai, et al. (2003)
found that higher scores on the Body Attitude Test (BAT) correlated with
higher scores on both the STAI and Self-Rating Depression Scale,
suggesting that those who suffer from eating disorders also experience
negative appreciation of body size, unfamiliarity with their bodies, and
general body dissatisfaction, and, therefore, have high trait anxiety.
Finally, trait anxiety also had a strong, predictive relationship with
overall MD symptoms, as illustrated by the relationship between the STAI
and MDI. The results suggest that trait anxiety integrates well into
existing models of MD. Because MD involves high levels of exercise to
obtain and maintain a certain body shape, the findings also support
research indicating that people who exercise excessively have higher
levels of obsessive-compulsive symptoms (Gulker, Laskis, & Kuba,
2001).

Similar to trait anxiety, obsessive-compulsive features are
strongly related to and were predictive of several factors of MD. In the
present study, a strong predictive relationship was found between
obsessive-compulsive features and body focus. This relationship could
indicate unhealthy obsessions in each of these three areas for men who
have high levels of MD symptoms. Individuals may, for example, be able
to find relief from their intrusive, obsessive thoughts about their
bodies by working out excessively or consuming a high protein diet or
supplements.

Obsessive-compulsive features were also strongly correlated with
and highly predictive of social physique anxiety and overall MD
symptoms. This finding suggests that a man's underlying obsession
with his own body magnifies the concerns he has regarding evaluation.
This could also be a sign of underlying obsessive-compulsive features.
Body focus could, therefore, be the primary focus of obsessional
thinking or compulsive behaviors.

Obsessive-compulsive features and overall MD symptoms were also
strongly related in this study. It could be that a predisposition
towards obsessive thinking and compulsive behaviors, when paired with
other factors linked to MD, lead to the expression of those obsessions
and compulsions through bodily preoccupation. For example, an individual
who suffers from obsessive thinking and is exposed to media images of
muscular men may manifest his or her compulsions by working out in an
effort to obtain an idealized body shape.

Social physique anxiety was also strongly positively correlated
with MD symptoms. These findings support past research of Grieve el al.
(in press), who found that men with higher levels of social physique
anxiety also had higher levels of MD symptoms. Conceptually, a
relationship between social physique anxiety and MD is understandable.
Even though they have very muscular body shapes, people with MD are
worried about how their bodies look and do not believe they measure up
to their standards. This discrepancy can lead to the development of
social physique anxiety.

Taken together, the findings support and extend the findings Maida
and Armstrong (2005). Similar relationships were noted for both studies
between obsessive-compulsive features, levels of anxiety, and drive for
muscularity. The present study also found a relationship between
anxiety, obsessive-compulsive symptoms, social physique anxiety, and
symptoms of Muscle Dysmorphia.

In general, the findings of the present study lend support to Maida
and Armstrong's (2005) assertion that MD should he placed within
the obsessive-compulsive spectrum of disorders. There is presently a
lack of consensus about the classification of MD. In addition to being
classified in the obsessive-compulsive spectrum of disorders, it has
also been classified as a Body Dysmorphic Disorder (Pope, Katz, &
Hudson, 1993), as an Eating Disorder (Goodale, Watkins, & Cardinal,
2001), and as part of the Obsessive Compulsive spectrum of disorders
(Maida & Armstrong, 2005). That obsessive-compulsive features were
found to be strong predictors for MD symptomatology, body attitude, and
social physique anxiety lends support to Maida and Armstrong's
placement of MD under the obsessive-compulsive spectrum.

The classification of MD is not simply a philosophical debate.
Correct classification has important implications for diagnosis and,
especially, for treatment. Placing the disorder within an appropriate
spectrum allows clinicians to devise appropriate treatments for the
disorder. Inappropriate placement may lead to the development of
potentially ineffective treatments and possible client endangerment. On
the treatment of MD, see Olivardia (2007).

Interestingly, this study found a relationship between aspects of
negative affect and MD, whereas previous research (Henson, 2004; Jonda,
2007) did not. The current study found both trait anxiety and
obsessive-compulsive features to be predictive of MD symptomatology.
Jonda's model of MD symptomatology noted a weak standardized
beta-weight (.101) between negative affect and MD symptomatology. This
difference may be the result of how each study measured negative mood
stales. Whereas the current study used specific assessment tools to
assess trait anxiety and obsessive-compulsive features, the study by
Jonda used the Positive and Negative Affect Scales (PANAS; Watson,
Clark, & Tellegen, 1988), an instrument designed to measure normal
mood fluctuations. Thus, it may be that negative emotional states need
to be of clinical significance before they substantively influence MD
symptoms.

Because the current study found that both obsessive-compulsive
features and trait anxiety were predictive of MD, future research may
wish explore how other psychological mood states relate to MD
symptomatology. Future research could expand the current study's
findings by incorporating, for example, clinical measures of depression
and anger.

The present study also has some limitations worth addressing. The
most obvious improvement would be a larger sample size. While the
overall reliability and the overall goodness of fit of the model
specified in the model of the study was strong, more participants would
improve statistical power and give opportunity to find greater numbers
of participants with clinical levels of MD. This study also lacked a
measure for media influence. As the existing literature has shown how
important media influence is in people with MD, future studies should
incorporate such a measure.

Another possibility to consider would be that MD may not fit into
any existing spectrum of disorders. While the literature attempts to
classify MD under a particular heading, it may also be possible that MD
presents us with a unique symptomatology and etiology that warrants its
own classification in a manner analogous to eating disorders.

Perhaps the most effective way to treat patients with MD is to
treat it as its own disorder rather than trying to classify it within
the body of existing disorders. In fact, it may be fruitful to consider
the diagnostic history of eating disorders which only attained the
status of a separate diagnostic category in the DSM-IV (Williamson,
Zucker, Martin, & Smeets, 2004). Such diagnostic clarification has
led both to a greater specificity of the subtypes within the eating
disorders (the binging-eating/purging and the restricting subtypes of
anorexia nervosa) and to the genesis of diagnosis specific treatments of
choice (interpersonal or cognitive-behavioral therapies for anorexia
nervosa). So, too, we can imagine the improved ability to identify
at-risk individuals, render accurate diagnoses, and advance the
treatment of individuals with MD, all as a consequence of finding a
diagnostically apt placement for the disorder outside of existing
groupings.

Finally, one limitation of the study is that it evaluates symptoms
of anxiety and MD within a normal college population. Participants who
met diagnostic criteria for MD were not recruited for participation;
therefore, the findings may only be generalizable to sub-clinical
populations. However, the range of scores on the MDI in this study (27
to 126) indicates that there were some participants who reported high
levels of MD symptoms. Further, college-age men are at a higher risk for
developing MD than other age groups of men or of women. While women can
meet diagnostic criteria for MD, the disorder is much more prevalent in
men than women. Therefore, college-age men are the population to which
these findings should be generalized.

In conclusion, while this study does not make any definitive
statement regarding the classification of MD, it does reveal that
anxiety and obsessive-compulsive symptoms are strongly related to high
levels of MD symptoms, lending support to Maida and Armstrong's
(2005) assertion that MD should be classified under the
obsessive-compulsive spectrum of disorders. This study brings
researchers one step closer to being able to classify MD appropriately
based upon its etiology and psychological comorbidity.